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Case report
Isolated convergence-retraction nystagmus secondary to intralesional haemorrhage of a pineal cyst: an easily missed neurological finding with potentially life-threatening consequences
  1. Kristine Woodward1,
  2. Amith Sitaram2 and
  3. Steven Peters1
  1. 1Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  2. 2University of Glasgow, Glasgow, UK
  1. Correspondence to Dr Steven Peters; stevenray.peters{at}


This case report describes a patient who presented to the emergency department with intermittent visual disturbance and was found to have convergence-retraction nystagmus. This occurred in the setting of supratherapeutic anticoagulation on warfarin for an aortic dissection graft repair. Urgent imaging demonstrated haemorrhagic transformation of a previously identified incidental pineal cyst. After close monitoring given the risk of secondary hydrocephalus, the patient was discharged in stable condition with symptom resolution and without any further significant complications. This case report highlights the importance of identifying subtle clinical findings and the risk of secondary haemorrhage of pineal cysts when on anticoagulation. While the risk of secondary hydrocephalus is a significant concern, clinically stable patients can be followed without need for neurosurgical intervention.

  • brain stem / cerebellum
  • neuroimaging
  • neuro-ophthalmology
  • warfarin therapy

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  • Contributors All authors contributed to the initial clinical assessment, writing of manuscript, conception and design, ongoing revisions and final approval of the submitted version. All authors agree to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated and resolved. KW drafted the manuscript and designed and produced figure 2. SP provided patient care, editing and design of the manuscript layout and design of figure 1. AS provided patient care, conception of the clinical case report, manuscript editing and planning.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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